Early versus late parenteral nutrition for critically ill term and late preterm infants.

Systematic review of randomized trials comparing early versus late parenteral nutrition in critically ill term and late preterm infants, defined as gestational age at least 34 weeks to day 28 of life. Evidence was drawn mainly from one randomized trial subgroup of 209 term infants, with one additional smaller trial from Turkey.

Early parenteral nutrition was started within 72 hours of NICU/PICU admission, while late parenteral nutrition was started after 72 hours. In the smaller Turkish trial, early PN began within the first 8 hours after birth with amino acids 1 g/kg/day and lipid emulsion 0.5 g/kg/day, whereas late PN used 0.5 g/kg/day amino acid and 0.5 g/kg/day lipid emulsion after 72 hours; both were advanced by 0.5 g/kg/day to a maximum of 3 g/kg/day.

Overall, evidence was insufficient to determine whether early or late parenteral nutrition improves outcomes, but the available trial data favored late PN for several short-term outcomes. In the 209-infant term subgroup, late PN was associated with lower in-hospital all-cause mortality (6/111 vs 15/98; RR 0.35), lower neonatal mortality (4/111 vs 12/98; RR 0.29), and fewer healthcare-associated infections (18/111 vs 30/98; RR 0.53). Late PN also shortened ICU stay by 3.3 days, hospital stay by 9.5 days, and mechanical ventilation by 3.4 days. A possible harm was more hypoglycaemia with late PN (26/111 vs 14/98; RR 1.64), and long-term neurodevelopmental outcomes were not available.

The evidence base was very small, with data mainly from a single randomized trial subgroup and only 209 term infants. Risk of bias, small sample size, and heterogeneity limited confidence in the findings, and the smaller trial did not report results in the provided text. Long-term neurodevelopmental outcomes were unavailable, and baseline illness severity differed between groups in the main trial.